Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia

Effect of skin tone on the accuracy of the estimation of arterial oxygen saturation by pulse oximetry: a systematic review

BACKGROUND

Pulse oximetry-derived oxygen saturation (SpO2) is an estimate of true arterial oxygen saturation (SaO2). The aim of this review was to evaluate available evidence determining the effect of skin tone on the ability of pulse oximeters to accurately estimate SaO2.

METHODS

Published literature was screened to identify clinical and non-clinical studies enrolling adults and children when SpO2 was compared with a paired co-oximetry SaO2 value. We searched literature databases from their inception to March 20, 2023. Risk of bias (RoB) was assessed using the QUADAS-2 tool. Certainty of assessment was evaluated using the GRADE tool.

RESULTS

Forty-four studies were selected reporting on at least 222 644 participants (6121 of whom were children) and 733 722 paired SpO2-SaO2 measurements. Methodologies included laboratory studies, prospective clinical, and retrospective clinical studies. A high RoB was detected in 64% of studies and there was considerable heterogeneity in study design, data analysis, and reporting metrics. Only 11 (25%) studies measured skin tone in 2353 (1.1%) participants; the remainder reported participant ethnicity: 68 930 (31.0%) participants were of non-White ethnicity or had non-light skin tones. The majority of studies reported overestimation of SaO2 by pulse oximetry in participants with darker skin tones or from ethnicities assumed to have darker skin tones. Several studies reported no inaccuracy related to skin tone. Meta-analysis of the data was not possible.

CONCLUSIONS

Pulse oximetry can overestimate true SaO2 in people with darker skin tones. The clinical relevance of this bias remains unclear, but its magnitude is likely to be greater when SaO2 is lower.

SYSTEMATIC REVIEW PROTOCOL

International Prospective Register of Systematic Reviews (PROSPERO): CRD42023390723.

Advancing pediatric perioperative care in India: A contemporary overview

BACKGROUND

In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care.

AIM

With this background, we aim to provide an overview of the present and future of healthcare in India.

METHODOLOGY

With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable.

RESULTS

With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships.

CONCLUSION

India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

Inequities in global cancer surgery: Challenges and solutions

The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.

Capnography access and use in Kenya and Ethiopia

PURPOSE

Lack of access to safe and affordable anesthesia and monitoring equipment may contribute to higher rates of morbidity and mortality in low- and middle-income countries (LMICs). While capnography is standard in high-income countries, use in LMICs is not well studied. We evaluated the association of capnography use with patient and procedure-related characteristics, as well as the association of capnography use and mortality in a cohort of patients from Kenya and Ethiopia.

METHODS

For this retrospective observational study, we used historical cohort data from Kenya and Ethiopia from 2014 to 2020. Logistic regression was used to study the association of capnography use (primary outcome) with patient/procedure factors, and the adjusted association of intraoperative, 24-hr, and seven-day mortality (secondary outcomes) with capnography use.

RESULTS

A total of 61,792 anesthetic cases were included in this study. Tertiary or secondary hospital type (compared with primary) was strongly associated with use of capnography (odds ratio [OR], 6.27; 95% confidence interval [CI], 5.67 to 6.93 and OR, 6.88; 95% CI, 6.40 to 7.40, respectively), as was general (vs regional) anesthesia (OR, 4.83; 95% CI, 4.41 to 5.28). Capnography use was significantly associated with lower odds of intraoperative mortality in patients who underwent general anesthesia (OR, 0.31; 95% CI, 0.17 to 0.48). Nevertheless, fully-adjusted models for 24-hr and seven-day mortality showed no evidence of association with capnography.

CONCLUSION

Capnography use in LMICs is substantially lower compared with other standard anesthesia monitors. Capnography was used at higher rates in tertiary centres and with patients undergoing general anesthesia. While this study revealed decreased odds of intraoperative mortality with capnography use, further studies need to confirm these findings.

Anaesthesia provision challenges in public hospitals of Pakistan's Punjab province: a qualitative study of expert perspectives

OBJECTIVES

Anaesthesia delivery in Pakistan remains limited to conventional intraoperative procedures, with research showing ongoing challenges in quality and resourcing. We aimed to identify systemic challenges in the delivery of the WHO-World Federation of Societies of Anaesthesiologists' (WHO-WFSA) 'highly recommended' standards of quality anaesthesia services for surgical support in Pakistan's Punjab province.

STUDY DESIGN AND SETTING

This single-method qualitative study included 22 semistructured interviews with purposively selected anaesthesia system experts in Punjab province, including heads of teaching hospital anaesthesia departments, healthcare commission (HCC) representatives and health department officials. We analysed data thematically, using deductive and inductive coding.

PARTICIPANTS

10 participants worked as anaesthesia department heads of teaching hospitals across Punjab, 5 worked for the HCC and 7 worked for the health department. All were selected purposively and had at least 5 years of experience working as head of department or serving in legislative departments.

RESULTS

We identified three themes experienced as major challenges within the specialty, namely anaesthetist recruitment and retention, quality of care and in-service training, and discrepancies between specialities. Findings indicated that workforce shortages and maldistribution, insufficient in-service training and standards, inadequate equipment maintenance and lack of anaesthesia representation in decision-making compromised anaesthesia provision quality and safety.

CONCLUSIONS

Improving anaesthesia provision in Punjab would require increasing physician and non-physician anaesthetist numbers and rotation to peripheral postings, strengthening training quality and ensuring availability of WFSA-specified essential equipment and supplies. To achieve essential anaesthesia provision standards, policy interventions are needed to, for example, balance anaesthesiologist and surgeon/obstetrician-gynaecologist numbers, require that anaesthesiology postgraduates work a few years in-country (eg, scholarship bonds), ensure in-service training attendance for skills updates and implement quality assurance standards for equipment and supplies.

Pulse oximetry training landscape for healthcare workers in low- and middle-income countries: A scoping review

Background

Pulse oximetry has been used in medical care for decades. Its use quickly became standard of care in high resource settings, with delayed widespread availability and use in lower resource settings. Pulse oximetry training initiatives have been ongoing for years, but a map of the literature describing such initiatives among health care workers in low- and middle-income countries (LMICs) has not previously been conducted. Additionally, the coronavirus disease 2019 (COVID-19) pandemic further highlighted the inequitable distribution of pulse oximetry use and training. We aimed to characterise the landscape of pulse oximetry training for health care workers in LMICs prior to the COVID-19 pandemic as described in the literature.

Methods

We systematically searched six databases to identify studies reporting pulse oximetry training among health care workers, broadly defined, in LMICs prior to the COVID-19 pandemic. Two reviewers independently assessed titles and abstracts and relevant full texts for eligibility. Data were charted by one author and reviewed for accuracy by a second. We synthesised the results using a narrative synthesis.

Results

A total of 7423 studies were identified and 182 screened in full. A total of 55 training initiatives in 42 countries met inclusion criteria, as described in 66 studies since some included studies reported on different aspects of the same training initiative. Five overarching reasons for conducting pulse oximetry training were identified: 1) anaesthesia and perioperative care, 2) respiratory support programme expansion, 3) perinatal assessment and monitoring, 4) assessment and monitoring of children and 5) assessment and monitoring of adults. Educational programmes varied in their purpose with respect to the types of patients being targeted, the health care workers being instructed, and the depth of pulse oximetry specific training.

Conclusions

Pulse oximetry training initiatives have been ongoing for decades for a variety of purposes, utilising a multitude of approaches to equip health care workers with tools to improve patient care. It is important that these initiatives continue as pulse oximetry availability and knowledge gaps remain. Neither pulse oximetry provision nor training alone is enough to bolster patient care, but sustainable solutions for both must be considered to meet the needs of both health care workers and patients.

Repeatability of Pulse Oximetry Measurements in Children During Triage in 2 Ugandan Hospitals

BACKGROUND

In low- and middle-income countries, health workers use pulse oximeters for intermittent spot measurements of oxygen saturation (SpO2). However, the accuracy and reliability of pulse oximeters for spot measurements have not been determined. We evaluated the repeatability of spot measurements and the ideal observation time to guide recommendations during spot check measurements.

METHODS

Two 1-minute measurements were taken for the 3,903 subjects enrolled in the study conducted April 2020-January 2022 in Uganda, collecting 1 Hz SpO2 and signal quality index (SQI) data. The repeatability between the 2 measurements was assessed using an intraclass correlation coefficient (ICC), calculated using a median of all seconds of non-zero SpO2 values for each recording (any quality, Q1) and again with a quality filter only using seconds with SQI 90% or higher (good quality, Q2). The ICC was also recalculated for both conditions of Q1 and Q2 using the initial 5 seconds, then the initial 10 seconds, and continuing with 5-second increments up to the full 60 seconds. Lastly, the whole minute ICC was calculated with good quality (Q2), including only records where both measurements had a mean SQI of more than 70% (Q3).

RESULTS

The repeatability ICC with condition Q1 was 0.591 (95% confidence interval [CI]=0.570, 0.611). Using only the first 5 seconds of each measurement reduced the repeatability to 0.200 (95% CI=0.169, 0.230). Filtering with Q2, the whole-minute ICC was 0.855 (95% CI=0.847, 0.864). The ICC did not improve beyond the first 35 seconds. For Q3, the repeatability rose to 0.908 (95% CI=0.901, 0.914).

CONCLUSIONS

Training guidelines must emphasize the importance of signal quality and duration of measurement, targeting a minimum of 35 seconds of adequate-quality, stable data. In addition, the design of new devices should incorporate user prompts and force quality checks to encourage more accurate pulse oximetry measurements.

[Risk factors for postoperative hypoxemia during transport to the postanesthesia care unit and influence of transport monitoring : A retrospective propensity score-matched databank analysis]

BACKGROUND

Within a central operating room area, after general anesthesia (GA) patients are at risk of hypoxemia during transport to the postanesthesia care unit (PACU); however, specific risk factors have not been conclusively clarified and uniform recommendations for monitoring vital signs during transport within a central operating room area complex do not exist. The purpose of this retrospective database analysis was to identify risk factors for hypoxemia during this transport and to determine whether the use of transport monitoring (TM) affects the initial value of peripheral venous oxygen saturation (S_pO₂) in the PACU.

MATERIAL AND METHODS

This analysis was performed on a retrospectively extracted dataset of procedures in GA within a central operating room area of a tertiary care hospital from 2015 to 2020. The emergence from GA was conducted in the operating room with subsequent transport to the PACU. The transport distance was between 31 and 72 m. Risk factors for initial hypoxemia in the PACU, defined as peripheral oxygen saturation (S_pO₂) below 90%, were determined using multivariate analysis. After splitting the dataset into patients without TM (group OM) and with TM (group MM) and propensity score matching, the influence of TM on initial S_pO₂ and the Aldrete score after arrival in the PACU were examined.

RESULTS AND DISCUSSION

From a total of 22,638 complete datasets included in the analysis, 8 risk factors for initial hypoxemia in PACU were identified: age > 65 years, body mass index (BMI) > 30 kg/m², chronic obstructive pulmonary disease (COPD), intraoperative airway driving pressure (∆p) > 15 mbar and positive endexpiratory pressure (PEEP) > 5 mbar, intraoperative administration of a long-acting opioids, first preoperative S_pO₂ < 97%, and last S_pO₂ < 97% measured after emergence from anesthesia before transport. At least 1 risk factor for postoperative hypoxemia was present in 90% of all patients. After propensity score matching, 3362 datasets per group remained for analysis of the influence of TM. Patients transported with TM revealed a higher S_pO₂ at PACU arrival (MM 97% [94; 99%], OM 96% [94; 99%], p < 0.001). In a subgroup analysis, this difference between groups remained in the presence of one or more risk factors (MM 97% [94; 99%], OM 96% [94; 98%], p < 0.001, n = 6044) but was not detectable in the absence of risk factors for hypoxemia (MM 97% [97; 100%], OM 99% [97; 100%], p < 0.393, n = 680). Furthermore, the goal of an Aldrete score > 8 at PACU arrival was achieved significantly more often in monitored patients (MM 2830 [83%], OM: 2665 [81%], p = 0.004). Critical hypoxemia (S_pO₂ < 90%) at PACU arrival had an overall low occurrence within propensity matched datasets and showed no difference between groups (MM: 161 [5%], OM 150 [5%], p = 0.755). According to these results, consistent use of TM leads to a higher S_pO₂ and Aldrete score at PACU arrival, even after a short transport distance within an operating room area. Consequently, it appears to be reasonable to avoid unmonitored transport after general anesthesia, even for short distances.

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training

BACKGROUND

Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists' perioperative care and what, if any, capacity gaps remain.

METHODS

We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care.

RESULTS

Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial.

CONCLUSION

Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

Regional anesthesia global health collaborations- a scoping review of current intervention methods

PURPOSE OF REVIEW

Perioperative anesthesia-related mortality is significantly higher in low-resource compared to high-resource countries. Regional anesthesia techniques can provide safety, cost, and access benefits when compared to general anesthesia in these settings but is underutilized primarily due to a lack of experienced educators and training opportunities. Academic institutions and international organizations are attempting to fill this educational gap through collaborations, but these efforts need examination for best practices going forward.

RECENT FINDINGS

Most collaborative anesthesia interactions between high and low resource areas have occurred between North America or Europe, and Africa or Asia and a majority have involved an educational intervention. Only 7% of the studies used a recognized framework to evaluate the intervention used in their research, such as the Kirkpatrick, REAIM or CFIR method. All recent studies reviewed reported a positive impact from educational collaborations. Only 7% of interventions have had a primary focus on regional anesthesia and most were reported between 2016 and 2022.

SUMMARY

Robust reports on international collaborations providing capacity enhancing educational interventions in regional anesthesia have increased in recent years but are still rare and should be encouraged going forward. Short courses supported by high-resource countries can be effective in low-resource areas when partnerships produce curricula that are well designed.

Tracheal Extubation Under Deep Anesthesia Using Transnasal Humidified Rapid Insufflation Ventilatory Exchange vs. Awake Extubation: An Open-Labeled Randomized Controlled Trial

Background

Tracheal extubation can be associated with several complications, including desaturation, agitation, hypertension, and tachycardia. We hypothesize that the use of transnasal humidified rapid insufflation ventilator exchange (THRIVE) immediately after extubation under deep anesthesia reduces the incidence of these adverse events.

Methods

One hundred patients who underwent elective abdominal surgery under general anesthesia were randomly assigned to undergo tracheal extubation under deep anesthesia employing THRIVE (THRIVE group) or awake extubation (CONTROL group). The primary outcome was the incidence of experiencing desaturation (SpO₂ < 90%) at any time during emergence from anesthesia. Secondary outcomes included variations in heart rate and blood pressure, comfort level, bucking, and agitation.

Results

The THRIVE group showed a lower incidence of desaturation than the CONTROL group (12 vs. 54%, OR = 0.22 [95% CI, 0.10-0.49], P < 0.001). Less patients in the THRIVE group experienced a 20% (or more) increase in mean arterial pressure (4 vs. 26%, OR = 0.15 [95% CI, 0.04-0.65], P = 0.002). THRIVE patients did not suffer from agitation or bucking, while in the CONTROL group agitation and bucking occurred in 22 and 58% of the patients, respectively. Additionally, the THRIVE group showed a lower incidence of uncomfortable experience than the CONTROL group (8 vs. 36%, OR = 0.22 [95% CI, 0.08-0.61], P = 0.001).

Conclusion

Tracheal extubation under deep anesthesia using THRIVE decreases the incidence of desaturation and adverse haemodynamic events and increases patient satisfaction. Extubation under deep anesthesia using THRIVE might be an alternative strategy in selected patient populations.

Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study

BACKGROUND

There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death.

METHODS

A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included.

RESULTS

Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6).

CONCLUSIONS

The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.

The impact of the Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia training course in Ethiopia: A mixed methods longitudinal cohort study

SummaryReducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia.We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018.Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline (n = 101, 69% response rate). Pre- and post-course MCQs (n = 121, n = 123 respectively) and pre- and post-course skills tests (n = 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up (n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training (P < 0.0001) and skills test scores improved from 56.5% to 83.2% (P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3-11 months post-training compared to baseline (P = 0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up.This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.

Acute respiratory illness among a prospective cohort of pediatric patients using emergency medical services in India: Demographic and prehospital clinical predictors of mortality

Background

In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India’s public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint.

Methods

Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of “shortness of breath”, or a “fever” with associated “difficulty breathing” or “cough”, were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality.

Results

A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17–10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0–28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77–5.71) and respiratory distress (OR: 3.72 CI: 2.17–6.36) were the strongest predictors of mortality at 30 days.

Conclusions

This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.

A profile of traumatic injury in the prehospital setting in India: A prospective observational study across seven states

BACKGROUND

Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population.

METHODS

We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality.

RESULTS

We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25-50) and were predominately male (72%, N = 2088), of lower economic status (97%, N = 2805 used a government issued ration card) and were from rural or tribal areas (74%, N = 2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4-14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2-7)), on-scene mobility (OR 2.8 (95% CI: 1.3-6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1-5)).

CONCLUSIONS

EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.

Priorities for peri-operative research in Africa

Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri-operative research agenda to ensure co-ordinated, collaborative research efforts across Africa in order to decrease peri-operative mortality. The objective was to determine the top 10 research priorities for peri-operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence-based practice guidelines for peri-operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri-operative outcomes associated with emergency surgery. These peri-operative research priorities provide the structure for an intermediate-term research agenda to improve peri-operative outcomes across Africa.

The path to safe and accessible anaesthesia care

The increasing focus on and importance of surgical care in achieving universal health coverage requires the development of safe and accessible anaesthesia services. Increasing access to care by supporting the necessary inputs to the anaesthesia system, including medications, equipment and personnel, must be accompanied by processes that support high-quality care, including support for education, and guidelines for standards, and training. As safe, high-quality care requires an integrated approach, each element must be supported together, i.e., in an integrated manner to ensure that anaesthesia care reaches those who need it, and in the safest possible manner. Several important efforts have been undertaken globally to address and foster these elements, and resources to guide these processes exist for low- and middle-income countries to improve them. This review highlights both the needs and resources for safe and high-quality care that patients deserve.

Newborn Resuscitation Skills in Health Care Providers at a Zambian Tertiary Center, and Comparison to World Health Organization Standards

BACKGROUND

Birth asphyxia is a leading cause of early neonatal death. In 2013, 32% of neonatal deaths in Zambia were attributable to birth asphyxia and trauma. Basic, timely interventions are key to improving outcomes. However, data from the World Health Organization suggest that resuscitation is often not initiated, or is conducted suboptimally. Currently, there are little data on the quality of newborn resuscitation in the context of a tertiary center in a lower-middle income country. We aimed to measure the competencies of clinical practitioners responsible for newborn resuscitation.

METHODS

This observational study was conducted over 5 months in Zambia. Health care professionals were recruited from anesthesia, pediatrics, and midwifery. Newborn skills and knowledge were examined using the following: (1) multiple-choice questions; (2) a ventilation skills test; and (3) 2 low-medium fidelity simulation scenarios. Participant demographics including previous resuscitation training and a self-efficacy rating score were noted. The primary outcome examined performance scores in a simulated scenario, which assessed the care of a newborn that failed to respond to basic interventions. Secondary outcome measures included apnea times after delivery and performance in the other assessments.

RESULTS

Seventy-eight participants were enrolled into the study (13 physician anesthesiology residents, 13 pediatric residents, and 52 midwives). A significant difference in interprofessional performance was observed when examining checklist scores for the unresponsive newborn simulated scenario (P = .006). The median (quartiles) checklist score (out of 18) was 14.0 (13.0-14.75) for the anesthesiologists, 11.0 (8.5-12.3) for the pediatricians, and 10.8 (8.3-13.9) for the midwives. A score of 14 or more was required to pass the scenario. There was no significant difference in performance between participants with and without previous newborn resuscitation training (P = .246). The median (quartiles) apnea time after delivery was significantly different between all groups (P = .01) with anesthetic and pediatric residents performing similarly, 61 (37-97) and 63 (42.5-97.5) seconds, respectively. The midwifery participants displayed a significantly longer apnea time, 93.5 (66.3-129) seconds. Self-efficacy rating scores displayed no correlation between confidence level and the primary outcome, Spearman coefficient 0.06 (P = .55).

CONCLUSIONS

Newborn resuscitation skills among health care professionals are varied. Midwives lead the majority of deliveries with anesthesiologists and pediatricians only being present at operative or high-risk births. It is therefore common that midwifery practitioners will initiate resuscitation. Despite this, midwives perform poorly when compared to anesthesia and pediatric residents. To address this discrepancy, a multidisciplinary, simulation-based newborn resuscitation program should be considered with continual clinical reenforcement of best practice.

Disseminating technology in global surgery

Background

Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.

Methods

This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.

Results

Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.

Conclusion

Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.

The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis plane block after caesarean section: a randomised controlled trial at a Ugandan regional referral hospital

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, side-effects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

Global Capnography Project (GCAP): implementation of capnography in Malawi - an international anaesthesia quality improvement project

The Lancet Commission on Global Surgery emphasised the importance of access to safe anaesthesia care. Capnography is an essential monitor for safe anaesthesia, but is rarely available in low‐income countries. The aim of this study was twofold: to measure the prevalence of capnography in the operating theatres and in intensive care units; and to determine whether its introduction was feasible and could improve the early recognition of critical airway incidents in a low‐income country. This is the first project to do this. Forty capnographs were donated to eight hospitals in Malawi. Thirty‐two anaesthesia providers received a 1‐day capnography training course with pre‐ and post‐course knowledge testing. Providers kept logbooks of capnography use and recorded their responses to abnormal readings. On follow‐up at 6 months, providers completed questionnaires on any significant patient safety incidents identified using capnography. In January 2017, at the commencement of the project, only one operating theatre had a capnograph. Overall, 97% and 100% ‘capnography gaps’ were identified in the theatres and intensive care units, respectively. The mean (SD) scores of our capnography multiple choice questionnaires improved after training from 15.00 (3.16) to 18.70 (0.99), p = < 0.001. The capnography equipment was appropriately robust and performed well. Six months following implementation, 24 (77%) anaesthesia providers reported recognising 44 oesophageal intubations and 28 (90%) believed that capnography had saved lives. This study has shown it is feasible to introduce capnography in a low‐income country, resulting in early recognition of critical airway incidents and ultimately helping to save lives. Building on the experience of the first trial of pulse oximetry implementation in low‐income countries in 2007, we believe this is one of the most important projects in anaesthesia safety in the last decade.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.